Provider Demographics
NPI:1205847746
Name:GOLDEN STATE EYE MEDICAL GROUP
Entity Type:Organization
Organization Name:GOLDEN STATE EYE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KHALED
Authorized Official - Middle Name:A
Authorized Official - Last Name:TAWANSY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-327-4499
Mailing Address - Street 1:6000 PHYSICIANS BLVD BUILDING D
Mailing Address - Street 2:SUITE 205
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93301-5840
Mailing Address - Country:US
Mailing Address - Phone:661-327-4499
Mailing Address - Fax:661-327-4381
Practice Address - Street 1:6000 PHYSICIANS BLVD BUILDING D
Practice Address - Street 2:SUITE 205
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-5840
Practice Address - Country:US
Practice Address - Phone:661-327-4499
Practice Address - Fax:661-327-4381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13086T152W00000X
156FX1800X, 207W00000X, 332B00000X
CAG30637208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA180012319OtherMEDICARE RAILROAD
CA0508080001Medicare NSC
CAZZZ12568ZMedicare PIN